Shock to the Senses

http://www.nytimes.com/2012/12/30/books/review/hallucinations-by-oliver-sacks.html

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Since his first extraordinary work, “Migraine,” was published in 1970, the neurologist Oliver Sacks has been writing a particular kind of medical literature. His detailed explications of a single patient’s symptoms, his emphasis on the subjective experience of illness, his willingness to share stories from his own life and his references to medical texts from earlier centuries are not only atypical of how most neurologists work today, they defy the status quo. And yet, Sacks’ work is part of a long tradition of descriptive, narrative, case-oriented medical writing he has himself called “romantic.”

The idea of a “romantic science” can be traced to Goethe. The German philosopher, poet and scientist opposed a mechanistic, analytical science of static categories for a fluid and organic one. A. R. Luria, the 20th-century Soviet neurologist, who was a mentor to and friend of Sacks, evoked the tension between “romantic” and “classical” science in his intellectual autobiography, “The Making of Mind.” “Romantic scholars,” he wrote, “do not follow the path of reductionism.” Instead they strive “to preserve the wealth of living reality.” Classical scholars work piecemeal toward the formulation of abstract laws, and in the process they sometimes “murder to dissect.” Romantics may err in the other direction when their “artistic preferences and intuition” take over. Luria sought a middle ground — a science that preserves the part without losing the synthetic whole. This is not an easy balance to achieve, but for Sacks, unlike many clinicians in his field, it remains an ideal.

“Hallucinations” covers a broad range of sensory disturbances — visual, auditory, olfactory and tactile. In his introduction, Sacks writes, “I think of this book, then, as a sort of natural history or anthology of hallucinations, describing the experiences and impact of hallucinations on those who have them, for the power of hallucinations is only to be understood from first-person accounts.” This apt characterization of the chapters that lie ahead also defines hallucination. It is by its very nature a perception that cannot be shared with other people. In hallucinatory perception, as in a dream, there is no “we” that perceives. There is only “I.”

Although Sacks tells the reader he will concentrate on “ ‘organic’ psychoses — the transient psychoses sometimes associated with delirium, epilepsy, drug use and certain medical conditions,” he includes a chapter, “On the Threshold of Sleep,” that treats hypnagogic hallucinations, the vivid imagery many people see before they fall asleep, and another, “The Haunted Mind,” which describes bereavement and traumatic hallucinations that would be classified as psychiatric not neurological phenomena. As Sacks knows, separating the physiological from the psychological is a philosophical conundrum that continues to plague both science and philosophy. But one of the pleasures of reading “Hallucinations” is understanding how complex human reality often trumps attempts to categorize it. As the 19th-century neurologist Jean Martin Charcot once remarked (and Freud recorded): “Theory is good, but it doesn’t prevent things from existing.”

What “exists” in hallucinatory experience is multifarious. Drawing from many sources, Sacks gathers together cases of people who have seen, heard, smelled and felt things and offers possible insights into the phenomena. There is no overarching neuroscientific theory of hallucination, just as there is no consensual theory of how the brain-mind works. As Patricia Boksa put it in a 2009 paper in The Journal of Psychiatry and Neuroscience, “Over all the literature reflects the perplexing challenges inherent in investigating a higher mental process like a hallucination. . . . Neural processes can only be shown to correlate with, not definitely to cause, hallucinations.” When Sacks cites new research by Olaf Blanke and Dominic ffytche, classic studies by Jean-Étienne Esquirol, Francis Galton and William James, as well as literary texts by Poe and Dostoyevsky, it is always with the understanding that research into the curious doings of the human mind is a developing dynamic process.

The documented cases range from the trivial (the postoperative phantasm of Kermit the Frog) to the poignant (the reappearance of a dead grandfather), to the horrifying (living people who take on the appearance of the dead). There are stories of nimble phantom limbs and painful contracted ones; of benign self-doubles and nasty, tormenting ones; of comforting voices and cruel, harassing ones; of hallucinating “Good Night, Irene” and full-blown orchestral scores.

The loss or deterioration of a sense is often linked to hallucinating. The brain appears to compensate for the deficit. The myriad visual hallucinations of Charles Bonnet syndrome are often seen in patients losing their eyesight, just as musical and auditory hallucinations frequently occur to those with impaired hearing. And, as Sacks points out, people with perfectly functioning senses will hallucinate spontaneously in sensory deprivation tanks. Every report from the field is fascinating, including Sacks’ own tales of his experiments with LSD, morphine and amphetamines, and the frightening perceptual transformations of delirium tremens that arrived after he stopped taking large amounts of chloral hydrate to sleep.

I have met dozens of physicians who came to their specialty for private reasons — either they or their loved ones suffered from the diseases or conditions they then set out to treat — but few of these doctors include their own pathologies or stories in their papers and lectures. This reticence is as theoretical as it is personal. The third-person, “objective” view rules science, and the medical professional who exposes himself or herself risks appearing “soft.” Sacks includes his own experiences as illustrative of a larger point. He believes the details and nuances of first-person reports matter in the practice of medicine, not only for making a diagnosis, but for understanding the patient’s story as a whole and how it affects both symptom and disease. There are growing numbers of people in science who agree with him.

The rise of narrative-medicine departments like the one directed by Rita Charon at Columbia University, in which doctors draw insights from and explore forms of literature for their work with patients; the growing criticism from within neuroscience itself of the computational theory of mind and its machine metaphors of software and hardware, wiring, and processing; and a rekindled awareness that the accumulation of ever more voluminous data does not constitute a theory of mind are signs of an upheaval in thought (at least in some circles). But these debates remain mostly inside academia.

Sacks does not weigh in on these controversies in “Hallucinations.” His philosophy is embedded in the work itself, which seeks to combine the romantic and classical. In “Migraine,” however, he addressed the imbalance between the two ­approaches explicitly: “By a historical irony, a real gain of knowledge and technical skill has been coupled with a real loss in general understanding.” Although this might be changing, it is still largely true. In a culture that devalues fiction, continues to graduate doctors with scant knowledge of medical history and produces one crude, reductive, philosophically naïve book on “the brain” after another, Oliver Sacks represents a different mode of thinking. Learned, quietly passionate and always curious, Sacks is a physician who has long understood that medicine is an art as well as a science.

<NYT_AUTHOR_ID> <p>Siri Hustvedt’s most recent book is a collection of essays, “Living, Thinking, Looking.”